The Impact of Crural Closure Versus Fundoplication During Nissen Fundoplication As Measured by Endoflip(r) Parameters

Andreas M Schneider, MD, Daniel D Bradley, MD, Brian E Louie, MD, Alexander S Farivar, MD, Ralph W Aye, MD. Swedish Medical Center Cancer Institute

Introduction: The two main components of Nissen Fundoplication (NF) are hiatal closure and creation of the fundoplication. Both contribute toward the repair but their individual influence remains controversial. We hypothesized that crural closure plays a significant and underappreciated role. We aimed to determine each separate influence on Diameter – minimum (Dmin), Cross-Sectional Area (CSA), Distensibility (Dist) and Compliance (Comp) as measured by Endoflip® during the repair.  

Methods: Randomized controlled prospective study. Patients included had documented gastroesophageal reflux disease, hiatal hernia < 5 cm, intact peristalsis and normal distal contractile integral. Patients were randomized to either hiatal closure followed by fundoplication (Group 1) or fundoplication followed by hiatal closure (Group 2). Endoflip® measurements were performed at predetermined critical steps throughout the procedure – pre dissection, after dissection, after the first and after the second component of the repair.

Results: A total of 16 patients, predominantly women (87.5%) were randomized. The groups were comparable in BMI and hiatal hernia size.  There was a trend toward impact of hiatal closure in both groups.  Between dissection and completion of the procedure, Group 1 had a decrease in all parameters but this did not reach statistical significance.  By comparison Group 2 had a significant decrease in all parameters. (Table 1 and Figure 1)

Conclusion: Both hiatal closure and fundoplication decrease the diameter, cross-sectional surface area, distensibility and compliance. When hiatal closure is followed by fundoplication the decrease appears less in comparison. Unopposed hiatal closure significantly amplifies the reduction in diameter, cross-sectional surface area, distensibility and compliance; thus, underlining its significance during Nissen repair.

Table 1. (mean)Group 1(n=7)   (p-value)Group 2(n = 9)       (p-value)
Dmin Pre-Post7.8+/-2.17.03+/-1.60.468.4+/-1.9 6.2+/-1.30.014
CSA Pre-Post55+/-28.740+/-19.40.2858.6+/-25.531.7+/-14.50.017
Dist Pre-Post1.9+/-1.41.5+/-0.60.412.2+/-1.20.9+/-0.50.012
Comp Pre-Post53+/-3033+/-25.60.4560+/-29.928.3+/-21.60.007

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